whohtmtb 2010 13 annex

Annex 1 - Evidence summary tables Recommended doses for first line medicines, taking into account the

comparative risk of hepatotoxicity for isoniazid, rifampicin and pyrazinamide Recommendations 1, 2 and 3

Use of intermittent regimens for the treatment of TB in children

Recommendations 4 and 5

Treatment of TB in infants (0 - 3 months of age) Recommendation 6

Streptomycin in the treatment of uncomplicated pulmonary TB in children Recommendation 7

Evidence base for treatment regimens for TB meningitis in children Recommendation 8

Evidence base for treatment regimens for osteo-articular TB in children Recommendation 9

Use of fluoroquinolones in children with MDR-TB Recommendation 10

RECOMMENDED DOSES FOR FIRST LINE MEDICINES, TAKING INTO ACCOUNT THE COMPARATIVE RISK OF HEPATOTOXICITY FOR INH, RMP AND PZA

When to start Recommendations Taking into account the comparative risk of drug-induced hepatotoxicity, the following doses are recommended for the treatment of pulmonary tuberculosis and tuberculous peripheral lymphadenitis: Isoniazid (H) 10mg/kg (range 10-15 mg/kg); maximum dose 300mg/day Rifampicin (R) 15mg/kg (range 10-20 mg/kg); maximum dose 600 mg/day Pyrazinamide (P) (35mg/kg (range 30-40 mg/kg) Ethambutol (E) 20mg/kg (range 15-25 mg/kg) (Strong recommendation, moderate level of evidence) Children living in settings with high HIV prevalence and/or high isoniazid resistance, with suspected or confirmed pulmonary tuberculosis or peripheral lymphadenitis, or children with extensive pulmonary disease living in low HIV prevalent or low H resistance settings should be treated with a four drug regimen (HRZE) for 2 months followed by a two drug regimen (HR) for 4 months at the following doses: H - 10 mg/kg (range 10-15 mg/kg); maximum dose 300 mg/day R - 15 mg/kg (range 10-20 mg/kg); maximum dose: 600 mg/day Z - 35 mg/kg (30-40 mg/kg) E - 20 mg/kg (15-25 mg/kg) (Strong recommendation, moderate quality evidence) Children with suspected or confirmed pulmonary tuberculosis or tuberculous peripheral lymphadenitis who live in a setting with a low HIV prevalence and/or low H resistance and children who are HIV negative can be treated with a three drug regimen (HRZ) for 2 months followed by a two drug (HR) regimen for 4 months at the following doses: H - 10 mg/kg (range 10-15 mg/kg); maximum dose 300 mg/day R - 15 mg/kg (range 10-20 mg/kg); maximum dose: 600 mg/day Z - 35 mg/kg (30-40 mg/kg) (Strong recommendation, moderate level of evidence)

Domains and considerations Quality of evidence A review by Donald (2009)1 searched the literature to find articles assessing antituberculosis drug-induced hepatotoxicity (ADIH) for three tuberculosis (TB) drugs isoniazid (H), rifampicin (R) and pyrazinamide (P). Seventeen studies assessed hepatotoxicity of TB treatment in children. Five considered all or undefined types of TB, 6 considered pulmonary or extrapulmonary TB and 6 considered TB meningitis (table 1). There were 11 studies that assessed hepatotoxicity of TB prophylaxis in children (table 2). Study populations ranged in age from 0 to


observational nature of most studies. In most of the reported cases, hepatotoxicity was either transient or there was no data to determine whether it persisted, and possible confounding factors like malnutrition, acetylator status or poor adherence were not adequately considered. Conclusions of literature review

Isoniazid doses of 5-15mg/kg alone or in the company of other drugs do not constitute an undue risk for the development of hepatotoxicity in children; Rifampicin has the capacity to precipitate INH hepatotoxicity; however the dosage of R did not appear to be a critical factor in this interaction. There is little evidence that PZA makes a significant contribution to ADIH.

The panel noted the absence of high quality evidence available to directly address the question of hepatotoxicity caused by the first line medicines for the treatment of tuberculosis in children. However, the panel took account of:

the long duration of clinical experience with these medicines for the treatment of TB in adults and children

a relatively large quantity of low quality observational studies in a variety of settings and paediatric populations that show no evidence of increased toxicity with these doses of the medicines

the potential risk of inefficacy of treatment if lower doses are used the risk of developing isoniazid resistance if low doses are used The relationship between mean inhibitory concentration (MIC) in adults and efficacy

outcomes the development of metabolic pathways which increase the metabolism in young children the high likelihood of reporting bias which would over-report the occurrence of

hepatotoxicty Uncertainty: YES, given low quality of the evidence and relative lack of paediatric evidence Risks/benefits Benefits improved efficacy and decreased resistance, especially for fast acetylators of isoniazid Risks development of isoniazid resistance if doses used are inadequate inefficacy of treatment if lower doses are used risk of drug-induced hepatotoxicity Benefits outweigh risks Values and acceptability In favour: long duration of clinical experience with these medicines for the treatment of TB in adults and children observational studies in a variety of settings and paediatric populations show no evidence of increased toxicity with these doses of the medicines dose-dependent hepatotoxicity is very rare want to achieve the same systemic exposure in children as in adults Against: there is some risk, but it is not clear exactly what it is based on the available evidence interpretation depends on your definition of hepatotoxicity and what level of toxicity you are

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willing to accept Uncertainty: YES, given lack of evidence Cost Cost was not considered an important issue due to the fact that the medicines are inexpensive and are often provided free of charge to countries by international agencies for national programmes Uncertainty: YES, given the lack of paediatric specific data and cost analyses. Feasibility currently no fixed dose combination drugs exist for the newly recommended dose strengths and regimens Uncertainty: No Gaps, research needs, comments While there is available data addressing, or including, assessment of hepatotoxicity of TB drugs, there is a relative lack of data specifically addressing hepatotoxicity in children All types of hepatotoxicity are reported, but it was not clear which type is responsible for the majority of cases There is a need for clear consistent definitions of hepatotoxicity Urgent requirement for further research in this area, including a population PK study and pharmacovigilance Final comment Strong recommendation for treatment using new higher doses for children. Overall, there was not convincing data that the new higher recommended dosages would cause more hepatoxicity reactions than the previously recommended dosages, while there was evidence from pharmacokinetic studies that using the previously recommended lower drug dosages, minimum inhibitory concentrations (MIC) may not be reached in children. TB=tuberculosis; H=isoniazid; R=rifampicin; P=pyrazinamide

Table 1: Hepatotoxicity treatment for active disease Trial

Design

N/age

Treatment duration

Type of treatment

Hepatotoxicity definition

Outcome

All or undefined types Gendrel 1989

OL 47 3 months-13 years, mean age 31.2 months

6 months INH/RMP doses INH 20mg/kg; RMP 25mg/kg treatment active disease

NR 30 patients (63.8%) had increase in aminotransferase levels 14 patients (29.2%) had aminotransferase >100IU/l many patients were malnourished, with 68% of malnourished patients having elevated aminotransferase levels

Ohkawa 2002

RR 117 (99 analysed) 0-16 years

NR INH/RMP + PZA or SM or EMB or SM+PZA or EMB+PZA doses INH 4-10mg/kg; RMP 10-20mg/kg; SM 20-30mg/kg; EMB 15-20mg/kg; PZA 200-300mg/kg*see footnote treatment active disease

severe hepatotoxicity ALT or AST 5 times ULN

8 patients (8.1%) developed severe hepatotoxicity multivariate logistic regression analysis indicated that age (OR=143; 95% CI: 4.2 to 4934.9) and administration of PZA (OR=0.60; 95% CI: 0.39 to 0.90) had a significant contribution to development of hepatotoxicity estimated probability of a patient at 1, 5 and 10 years developing hepatotoxicity when receiving PZA with RMP and INH would be 0.95, 0.72 and 0.16, respectively

Ormerod 1996

RR 267 0-19 years

9-15 months

child-specific regimens not provided, doses for children were INH 10mg/kg; RMP 10mg/kg; PZA 30mg/kg; EMB 15mg/kg treatment active disease

hepatitis defined as biochemically confirmed jaundice and/or elevation serum ALT >5 times pretreatment level

hepatitis occurred in 2 patients (0.75%)

Padmini 1993

OL 83

Trial

Design

N/age

Treatment duration

Type of treatment


Outcome

1-12 years RMP/SM/INH/PZA + 10 EMB/INH doses INH 20mg/kg in first 2 months then 12mg/kg; RMP 12mg/kg; SM 40mg/kg; PZA 30mg/kg; EMB 17.5mg/kg treatment active disease

137 patients continued to second phase of treatment (EMB/INH) and of these, jaundice was observed in 1 (0.7%)

Pulmonary and/or extrapulmonary tuberculosis Martinez-Roig 1986

OL 74 4 months-15 years

9-18 months

RMP/INH + SM for 1.5 months then EMB for 1.5 months doses RMP 10mg/kg; INH 7mg/kg; SM 25mg/kg; EMB 15mg/kg treatment active disease

NR hepatotoxicity occurred in 27 (37%) of patients 5 patients (7%) had clinical manifestations

OBrien 1983

RR 874 45u/L 11 (19.6%) of those with normal hepatic enzymes before treatment showed increased ALT values with treatment none of the 11 patients showed clinical signs of hepatotoxicity and

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Trial

Design

N/age

Treatment duration

Type of treatment


Outcome

age 4.5 years treatment active disease treatment was not interrupted Seth 1989 OL 66

1.5-13 years 6 months INH/RMP

doses INH 10mg/kg; RMP 12mg/kg treatment active disease

NR no patients (either rapid or slow acetylators) developed signs of hepatotoxicity

Tsakalidis 1992

OL 36 8 months-12 years, mean age 5.5 years

6 months 2 INH/RMP/PZA + 4 INH/RMP doses INH 10-12mg/kg; RMP 10-12mg/kg; PZA 30-35mg/kg treatment active disease

NR 5 patients (13.9%) had rise on serum transaminase and uric acid values 3 patients (8.3%) had elevated serum transaminase liver enzymes returned to normal within 2 months without treatment modification

Tuberculosis meningitis Donald 1987

OL 56 5-144 months, median age 22 months

8 weeks INH/RMP/PZA/ETH doses INH 20mg/kg; RMP 20mg/kg; PZA 40mg/kg; ETH 15mg/kg treatment active disease

normal ALT

Trial

Design

N/age

Treatment duration

Type of treatment


Outcome

Ramachan dran 1980

OL 76 1-12 years

1 year 2 RMP/INH/SM + SM/EMB/INH 4 + 6 INH/SM doses INH 12-20mg/kg; RMP 12mg/kg; SM 40mg/kg; EMB 17.5mg/kg treatment active disease

NR 11 of 22 children (50%) given INH 20mg/kg developed clinical jaundice 8 of 40 children (20%) given INH 12mg/kg developed clinical jaundice

Tsagaro poulou-Stinga 1985

OL 44 4-14 years, mean age 4.5 years

NR INH/RMP doses INH 15-20mg/kg; RMP 15mg/kg treatment active disease

ALT >100 units 36 patients (82%) had hepatotoxic reaction (ALT >100 units) during treatment 15 of the 36 patients had jaundice no correlation between ALT values and duration of therapy in 22 of 36 patients liver function returned to normal without alteration of drug regimen

Visudhiphan 1989

RR 51 7 months-14 years

1 year INH/RMP doses INH 10-15mg/kg; RMP 15mg/kg

NR 4 patients (7.8%) had elevated ALT and AST Alt and AST levels decreased in 3 of 4 patients who had RMP dose decreased to 10mg/kg

TB=tuberculosis; NA= not available; NR=not reported; R=randomised; DB=double-blind; OL=open-label; RR=retrospective review; Rev=review; PK=pharmacokinetic; MC=multicentre; INH=isoniazid; RMP=rifampicin; EMB=ethambutol; ETH=ethionamide; SM=streptomycin; PZA=pyrazinamide; PAS=para-aminosalicylic acid; PYR=pyridoxine; ALT=alanine aminotransferase; AST=aspartate aminotransferase; LFT=liver function test; GGT=-glutamyl transferase; LTBI=latent tuberculosis infection; ULN=upper limit of normal *NB. PZA dose as presented in the publication. This may be an error, with dose more likely to be 20-30mg/kg. Although maybe not as the paper also said max dose

9Table 2: Hepatotoxicity - prophylaxis Trial

Design

N/age

Treatment duration

Type of treatment


Outcome

Byrd 1979 OL 0-9 years: 19 10-19 years: 44

1 year INH dose NR prophylaxis

AST 100IU/ml (5 times normal) no children discontinued due to elevated AST; no other child-specific results reported

Dash 1980 RR 644 3 times normal in presence of symptoms compatible with liver injury or transaminases >5 times normal in absence of symptoms

incidence of hepatotoxicity 0% in 0-14 year olds

Nakajo 1989

RR 564 3 months-18 years, mean age 8 years

1 year INH 10mg/kg prophylaxis in children with TB infection

elevation in ALT or AST >100 IU/L with or without elevation in serum bilirubin

1/564 (0.18%) with ALT/AST >100 IU/L and discontinued INH 39 children (6.9%) with signs or symptoms of hepatotoxicity, however all continued INH

Ormerod 1987

RR 339 Age NR

6 or 9 months

INH/RMP/PYR doses INH 10mg/kg; RMP 10mg/kg; PYR 10mg/kg prophylaxis

NR paper reports that no cases of obvious liver function abnormalities observed

Palusci 1995

RR 39 6 months-18 years, mean age 12.7 years

NR INH, dose NR prophylaxis in children with TB infection

NR 11 of 39 (3.5%) had symptoms suggestive of hepatitis and 1 had transaminase elevation 2 of remaining 28 children (7.1%) had elevated LFTs

Rapp OL 116 NR INH 10-15mg/kg normal AST defined as AST

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Design

N/age

Treatment duration

Type of treatment


Outcome

Trial 1978 10 and

References Table 1. Hepatotoxicity - treatment for active disease Gendrel D, Nardou M, Mouba JF, Gahouma D, Moussavou A, Boguikouma JB. Hpatotoxicit de lassociation isoniazide-rifampicine chez lenfant africain. Arch Fr Pediatr 1989; 46: 645-648. Ohkawa K, Hashiguchi M, Ohno K, et al. Risk factors for antituberculous chemotherapy induced hepatotoxicity in Japanese pediatric patients. Clin Pharmacol Ther 2002; 72: 220-226. Ormerod LP, Horsfield N. Frequency and type of reactions to antituberculosis drugs: observations in routine treatment. Tuberc Lung Dis 1996; 77: 37-42. Padmini R, Srinivasan S, Nalini P, Mahadevan S. Short course chemotherapy for tuberculosis in children. J Trop Pediatr 1993; 39: 361-364. Parasarthy R, Sarma GR, Janardhanam B, et al. Hepatic toxicity in South Indian patients during treatment of tuberculosis with short-course regimens containing isoniazid, rifampicin and pyrazinamide. Tubercle 1986; 67: 99-108. Martinez-Rog A, Cam J, Llorens-Terol J, de la Torre R, Perich F. Acetylation phenotype and hepatotoxicity in the treatment of tuberculosis in children. Pediatrics 1986; 77: 912-915. OBrien RJ, Long MW, Cross FS. Hepatotoxicity from isoniazid and rifampin among children treated for tuberculosis. Pediatrics 1983; 72: 491-499. Reis FJC, Bedran MBM, Moura JAR, Assis I, Rodrigues MESM. Six-month isoniazid-rifampin treatment for pulmonary tuberculosis in children. Am Rev Respir Dis 1990; 142: 996-999. Snchez-Albisua I, Vidal ML, Joya-Verde G, Castillo FD, De Jos MI, Garca-Hortelano J. Tolerance of pyrazinamide in short course chemotherapy for pulmonary tuberculosis in children. Pediatr Infect Dis J 1997; 16: 760-763. Seth V, Beotra A. Hepatic function in relation to acetylator phenotype in children treated with antitubercular drugs. Indian J Med Res 1989; 89: 306-309. Tsakalidis D, Pratsidou P, Hitoglou-Makedou A, Tzouvelekis G, Sofroniadis I. Intensive short course chemotherapy for treatment of Greek children with tuberculosis. Pediatr Infect Dis J 1992; 11: 1036-1042. Donald PR, Schoeman JF, OKennedy A. Hepatic toxicity during chemotherapy for severe tuberculous meningitis. Am J Dis Child 1987; 141: 741-743.

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Donald PR, Schoeman JF, van Zyl LE, De Villiers JN, Pretorius M, Springer P. Intensive short course chemotherapy in the management of tuberculous meningitis. Int J Tuberc Lung Dis 1998; 2: 704-711. Faella FS, Pagliano P, Attanasio V, et al. Factors influencing the presentation and outcome of tuberculous meningitis in childhood. In Vivo 2006; 20: 187-192. Ramachandran P. Chemotherapy of tuberculous meningitis with isoniazid plus rifampicin - interim findings in a trial in children. Ind J Tuberc 1980; 27: 54-62. Tsagaropoulou-Stinga H, Mataki-Emmanouilidou T, Karida-Kavalioti S, Manios S. Hepatotoxic reactions in children with severe tuberculosis treated with isoniazid-rifampin. Pediatr Infect Dis J 1985; 4: 270-273. Visudhiphan P, Chiemchanya S. Tuberculous meningitis in children: treatment with isoniazid and rifampicin for twelve months. J Pediatr 1989; 114: 875-879. Table 2. Hepatotoxicity - prophylaxis. Byrd RB, Horn BR, Solomon DA, Griggs GA. Toxic effects of isoniazid in tuberculosis chemoprophylaxis. Role of biochemical monitoring in 1,000 patients. JAMA 1979; 241: 1239-1241. Dash LA, Comstock GW, Flynn JPG. Isoniazid preventive therapy. Retrospect and prospect. Am Rev Respir Dis 1980; 121: 1039-2044. Kopanoff DE, Snider DE, Caras GJ. Isoniazid-related hepatitis. Am Rev Respir Dis 1978; 117: 991-1001. LoBue PA, Moser KS. Use of isoniazid for latent tuberculosis infection in a public health clinic. Am J Respir Crit Care Med 2003; 168: 443-447. Nakajo MM, Rao M, Steiner P. Incidence of hepatotoxicity in children receiving isoniazid chemoprophylaxis. Pediatr Infect Dis J 1989; 8: 649-650. Ormerod LP. Reduced incidence of tuberculosis by prophylactic chemotherapy in subjects showing strong reactions to tuberculin testing. Arch Dis Child 1987; 62: 1005-1008. Palusci VJ, OHare D, Lawrence RM. Hepatotoxicity and transaminase measurement during isoniazid chemoprophylaxis in children.Pediatr Infect Dis J 1995; 14: 144-148. Rapp RS, Campbell RW, Howell JC, Kendig EL. Isoniazid hepatotoxicity in children. Am Rev Respir Dis 1978; 118; 794-796.

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Spyridis NP, Spyridis PG, Gelesme A, et al. The effectiveness of a 9-month regimen of isoniazid alone versus 3- and 4-month regimens of isoniazid and rifampin for treatment of latent tuberculosis infection in children: results of an 11-year ramdomized study. Clin Infect Dis 2007; 45; 715-722. Tortajada C, Martinez-Lacasa J, Snchez F, et al. Is the combination of pyrazinamide plus rifampicin safe for treating latent tuberculosis infection in persons not infected by the human immunodeficiency virus? Int J Tuberc Lung Dis 2005; 9: 276-281. Villarino ME, Ridzon R, Weismuller PC, et al. Rifampin preventive therapy for tuberculosis infection: experience with 157 adolescents. Am J Respir Crit Care Med 1997; 155: 1735-1738.

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Use of intermittent regimens for the treatment of TB in children

Which treatment regimen Recommendations Children with suspected or confirmed pulmonary tuberculosis or tuberculous peripheral lymphadenitis living in settings with high HIV prevalence (or with confirmed HIV infection) should not be treated with intermittent regimens (i.e. twice or thrice weekly doses). (Strong recommendation, low to moderate evidence against the use of intermittent treatment in children) In the continuation phase of treatment, in settings with well established directly observed therapy, thrice weekly regimens might be considered for children known to be HIV uninfected. (Weak recommendation, very low quality evidence for use of intermittent treatment in children in specific settings)

Domains and considerations Quality of evidence Six studies assessed the effectiveness of intermittent therapies in children (Table 1). The quality of the RCTs was low due to lack of reporting of the method of randomization, allocation concealment, and blinding. One study that concluded there was no difference between daily and intermittent treatment regimens had not compared identical regimens (Ramachandran et al. 1998); the intermittent arm included the use of pyrazinamide with isoniazid and rifampicin, while the daily arm only included isoniazid and rifampicin. Four of the RCTs (466 children) were included in a published meta-analysis (Menon et al. 2010) The results of the pooled estimates of effect suggested that children receiving twice weekly intermittent therapy were less likely to be cured than those receiving daily therapy (per protocol analysis: OR 0.27, 96% CI 0.15-0.51; intention to treat analysis: OR 0.66; 95% CI 0.23-1.84). There were no high quality studies of thrice weekly intermittent treatment regimens in children. There were no data pertaining to the use of intermittent therapy for the treatment of TB in HIV positive children. Uncertainty: YES, given the low quality of evidence assessing the use of intermittent regimens in children Risks/benefits Benefits Limited evidence of benefits In some regions and countries thrice weekly intermittent regimens have been successfully used in their directly observed therapy programmes for the treatment of tuberculosis in adults and children. Recommending changing the well established practice may result in excluding children from directly observed therapy (DOT). Risks The metabolism of these medicines in children makes it more likely that intermittent treatment regimens may result in inadequate exposure to the medicines, therefore increasing the risk of inefficacy. This is supported by evidence from adult studies where adult patients using intermittent therapy have a higher risk of treatment failure and developing multidrug resistant TB. Uncertainty: YES, given lack of conclusive evidence for the use of intermittent regimens in children Values and acceptability

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Use of intermittent regimens for the treatment of TB in children In favour: Do not want children to be excluded from well established directly observed therapy programmes in countries with a low prevalence of HIV Against: Inefficacy of treatment if twice weekly intermittent regimens are used Uncertainty: YES, given lack of evidence Cost There are no data available assessing the costeffectiveness of the use of intermittent treatment regimens for tuberculosis in children. It may not be appropriate to apply results of cost-effectiveness analyses in adult populations to children, given that the factors that impact on cost-effectiveness, such as treatment efficacy and safety and relative cost, are likely to differ between adults and children. Uncertainty: YES, given lack of data and uncertainty regarding applicability of results from other populations. Feasibility Current evidence does not strongly support intermittent regimens for the treatment of TB in children Uncertainty: YES, given lack of evidence Gaps, research needs, comments There are no high quality randomised controlled trials assessing thrice weekly treatment regimens for the treatment of TB in children. Final comment The panel noted that some regions and countries have successfully used thrice weekly intermittent regimens in their directly observed therapy programmes for the treatment of tuberculosis in adults and children. Recommending changing the well established practice may result in excluding children from directly observed therapy (DOT). However, it was highlighted that this should only be considered in settings with a low HIV prevalence and a well established DOT programme.

Table 1. Summary of evidence for use of intermittent regimens in children Citation Study

Design/location Participants Number and age

Intervention (drugs used in mg/kg)

Follow-up Results Adverse events

Kansoy et al. 1996

RCT, Turkey 35 Mean age 7.6 years

Intermittent (twice weekly): n=18, 2m SHR / 8.5m HR S 20; H 15; R 15 Daily: n=15, 40d SHR / 9m HR / 3m H S 20; H 15; R 15

12 months Cure: Intermittent 100% (18/18) Daily 100% (15/15) Adherence: Information not available Relapse: 0

Transaminitis (n=1)

Ramachandran et al. 1998

RCT, Chennai, India

141 56% < 5 years

Intermittent (thrice/twice weekly): n=69, 2m HRZ thrice weekly followed by 4m HR twice weekly H 15; R 12; Z 45 Daily: n=68, 9m HR H 6; R 12

60 months Cure: Intermittent 48% (33/69) Daily 60% (41/68) Adherence: Information not available Relapse: 1in daily group

Jaundice (n=3)

Kumar et al. 1990

RCT, Chandigarh, India

76 1-15 years

Intermittent (twice weekly): n=37, 2m HRZ / 4m HR H 20-30; R 10-15; Z 50-60 Daily: n=39, 2m HRZ / 4m HR H 10-15; R 10-15; Z 20-30

24 months Cure: Intermittent 97% (31/32) Daily 100% (31/31) Adherence: Information not available Relapse: 0

No serious adverse effects reported. Vomiting (n=6); Joint pains (n=2)

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Citation Study Design/location

Participants Number and age

Intervention (drugs used in mg/kg)

Follow-up Results Adverse events

Te Water Naude et al. 2000

Open RCT, South Africa

213 Mean 2.1 years

Intermittent (twice weekly): n=95, 2m HRZ / 4m HR H 15; R 15; Z 55 Daily: n=118, 6m HRZ five days a week H 10; R 10; Z 25

30 months Cure: Intermittent 89% (85/95) Daily 97% (114/118) Adherence: Intermittent 79% vs. Daily 77% Relapse: 1 in intermittent group

Vomiting reported in intermittent group in children receiving Z at dosage of 62.5mg/kg. Resolved when dose reduced to Z 55mg/kg

Gcmen et al. 1993

Retrospective review, Turkey

130 Aged 6 mths to 17 years

110 children received: H 10-15; R 10-15; S 30 daily for 15 days, followed by similar doses of H and R twice weekly for 8.5 mths. 20 children received: same regimen without streptomycin

1 yr to 14.5 yrs

Cure: 100%; 84% clinical recovery within 1st mth; 20% radiological recovery within 1st 3mths and completed at 1yr Adherence: Intermittent 79% vs. Daily 77% Relapse: 1 case 18 mths after treatment completion

No serious adverse effects reported. Transient increase in liver enzymes (n=1)

Al-Dossary et al. 2002

Prospective study, USA

185 Aged 5 mths to 17 yrs

Wk 1-2(daily treatment): H 10-15; R 10-20; Z 20-40 Wk 3-8(twice weekly): H 20-40; R 10-20; Z 50-70 Wk 9-24 (twice weekly): H 20-40; R 10-20

Not stated Cure: 37% had complete resolution of disease at the end of treatment Adherence: 16 cases had poor adherence Relapse: 1 case; 4 yrs after treatment completion

Vomiting and skin rash (n=2). Gastrointestinal disturbances (n=9)

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References Al-Dossary FS, Ong LT, Correa AG, Starke JR. Treatment of childhood tuberculosis with a six month directly observed regimen of only two weeks of daily therapy. Pediatr Infect Dis J 2002; 21: 91-97. Gmen A, zelic U, Kiper M, et al. Short course intermittent chemotherapy in childhood tuberculosis. Infection 1993; 21: 324-327. Kansoy S, Kurta N, Akit S, Aksoylar S, Yaprak I, alayan S. Superiority of intermittent-short course chemotherapy in childhood pulmonary tuberculosis. Turkish J Med Sci 1996; 26: 41-43. Kumar L, Dhand R, Singhi PD, Narasimha KL, Katariy S. A randomized trial of fully intermittent vs. daily followed by intermittent short course chemotherapy for childhood tuberculosis. Pediatr Infect Dis J 1990; 19: 802-806. Menon P, Lodha R, Sivanandan S, Kabra S. Intermittent or daily short course chemotherapy for tuberculosis in children: meta-analysis of randomized controlled trials.Indian Pediatrics 2010; 47: 67-73. Ramachandran P, Kripasankar AS, Duraipandian M. Short course chemotherapy for pulmonary tuberculosis in children. Indian J Tuberc 1998; 45: 83-87. Te Water Naude JM, Donald PR, Hussey GD, et al. Twice weekly vs. daily chemotherapy for childhood tuberculosis. Pediatr Infect Dis J 2000; 19: 405-410.

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TREATMENT OF TB IN INFANTS (0 - 3 MONTHS OF AGE)

Which treatment regimen Recommendations Infants (0-3 months of age) with suspected or confirmed pulmonary tuberculosis or tuberculosis peripheral lymphadenitis in settings with high HIV prevalence and/or high isoniazid resistance or extensive pulmonary disease living in low HIV prevalent or low H resistance settings should be promptly treated with a four drug (HRZE) regimen for 2 months followed by a two drug (HR) regimen for 4 months at the following doses: H 10 mg/kg (range 10-15 mg/kg); maximum dose: 300 mg/day R 15 mg/kg (range 10-20 mg/kg); maximum dose: 600 mg/day Z 35 mg/kg (30-40 mg/kg) E 20 mg/kg (15-25 mg/kg) (Strong recommendation, low quality evidence) Infants (0-3 months of age) with suspected or confirmed pulmonary tuberculosis or tuberculosis peripheral lymphadenitis in a setting with a low HIV prevalence and/or low H resistance and infants aged 0-3 months who are HIV negative can be treated with a three drug regimen (HRZ) for 2 months followed by a two drug (HR) regimen for 4 months at the following doses : H 10mg/kg (range 10 15 mg/kg); maximum dose: 300 mg/day R 15mg/kg (range 10-20 mg/kg), maximum dose: 600 mg/day Z (35mg/kg (range 30-40 mg/kg) (Strong recommendation, low quality evidence)

Domains and considerations Quality of evidence There are no data specifically addressing the treatment of TB in children

TREATMENT OF TB IN INFANTS (0 - 3 MONTHS OF AGE) The lack of comparative data, the range of doses used and the lack of data in the relevant population suggest that there is currently no strong evidence base for treatment recommendations for children aged 0 to 3 months. The data presented in the tables below represents the available evidence and should be interpreted with caution given the lack of data in patients

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TREATMENT OF TB IN INFANTS (0 - 3 MONTHS OF AGE) Cost There are no data available assessing the costeffectiveness of TB treatment regimens in children aged 0 to 3 months. This is reasonable given lack of data for this patient population. It may not be appropriate to apply results of cost-effectiveness analyses in adult populations to this younger population, given that the factors that impact on cost-effectiveness, such as treatment efficacy and safety and relative cost, are likely to differ between adults and children. Uncertainty: YES, given lack of data and uncertainty regarding applicability of results from other populations. Feasibility due to the absence of PK, efficacy and safety data, the exact dose for children < 3 months old cannot be given Uncertainty: YES, given lack of evidence Gaps, research needs, comments The panel noted the very limited systematic clinical data describing treatment and outcomes of the treatment of TB in this age group PK studies in children less than 3 months of age Final comment Treatment may require dose adjustment to take into account the affect of age and development on drug disposition (absorption, distribution, metabolism and excretion) and possible toxicity in very young infants. This should be done by a clinician experienced in the management of paediatric tuberculosis

Table 1: Summary of studies including children aged 0 to 6 months of age Study

Design/location

Patient

population

Number in target population

(0 to 6 months)a

Drug(s)

Outcomes Studies with children < 6 months of age Abernathy 1983 cohort study

short-term treatment of TB USA

50 children aged 4 months to 15 years with TB

6 children

Study

Design/location

Patient

population


(0 to 6 months)a

Drug(s)

Outcomes Kiper 1998 cohort study

Turkey 15 children median age 4.68 months

15 INH 10-15mg/kg+RMP 10-15mg/kg+SM 30mg/kg for 15 days followed by INH 10-15mg/kg+RMP 10-15mg/kg for 8.5 months 6 children received the above regimen and 9 children received similar regimen without SM

clinical improvement in all children within 15 to 30 days, radiological improvement in 3 to 6 months moderately elevated serum levels of liver enzymes in 3 children, which returned to normal when RMP dose reduced to 5mg/kg

Kobayashi 2002 case report Japan

1 child 15 days old

1 INH 10mg/kg + RMP 10mg/kg + PZA 20mg/kg + SM 20mg/kg + vitamin B6 daily for 2 month at 4 months of age treatment changed to SM 20mg/kg twice weekly and RMP 10mg/day daily

good response without any sequelae within 1 year from discharge at 4 months child developed signs of cerebral hypertension and was diagnosed with cerebral haemorrhage and vitamin K deficiency

Sneag 2007 retrospective review of medical records prophylaxis for MDR-TB South Africa

5 children median age 0.4 years one child 13.3 years one child HIV positive all exposed to MDR-TB contacts

4 INH 10mg/kg/day for 14 months INH 5mg/kg/day for 3 months from birth then INH/RMP/PZA 5/10/25 mg/kg/day for 2 months INH/RMP/PZA 5/10/25 mg/kg/day from age 1 for 3 months INH/RMP 10/10mg/kg/day from birth for 3 months INH/RMP/PZA 5/10/25 mg/kg/day from birth for 2 months

all treatment regimens were inadequate in preventing MDR-TB in children exposed to MDR-TB contacts all patients were eventually treated with high dose H (15-20mg/day) plus Z/E/Eth/ofloxacin and amikacin. Four children became culture-negative within 3 months

Stewart 1976 open-label prophylactic use of

82 infants 82 INH 8mg/kg for 8 weeks no infants developed tuberculosis

23

Study

Design/location

Patient

population


(0 to 6 months)a

Drug(s)

Outcomes isoniazid following exposure to TB case UK

Unknown if children

Study

Design/location

Patient

population


(0 to 6 months)a

Drug(s)

Outcomes of short-course intermittent chemotherapy in children with TB Turkey

aged 6 months to 17 years

16 children (12%) aged 0 to 1 year

10-15mg/kg+RMP 10-15mg/kg+SM 30mg/kg daily for 15 days, followed by INH+RMP at same dosage twice weekly for 8.5 months 20 children received same regimen without SM

one case of relapse after 18 months increase in liver enzymes in one case (

Study

Design/location

Patient

population


(0 to 6 months)a

Drug(s)

Outcomes notifications within a few years of introduction reduction n duration of prophylaxis to 4 and 3 months showed no increase in proportion of notifications

Reis 1990 cohort study Brazil

117 children aged 6 months to 15 years

none INH 10mg/kg+RMP 15mg/kg excellent clinical/radiologic response in all patients no relapses occurred during follow-up 3 patients had side effects which disappeared after reduction of doses to 5-10mg/kg

Sanchez-Albuisa 1997

open-label study of tolerance of short course PZA Spain

114 children aged 6 months to 15 years

none INH 10mg/kg+RMP 15mg/kg+PZA 20-25mg/kg for 2 months followed by INH/RMP at same doses for 4 months

adverse effects mild in all cases; no signs of clinical hepatotoxicity increase in uric acid concentration in 92.2% of patients but no adverse effects associated with such

Schaaf 2002 observational study assessing chemoprophylaxis in children with household contact with adults with MDR-TB South Africa

125 children median age 28 months

unknown range of prophylaxis and treatment regimens including INH, PZA, Eth, EMB; dose not reported

2 of 41 (5%) who received prophylaxis developed TB all children who developed TB were clinically and radiologically cured after 30 months follow-up

Te Water Naude 2000

open-label randomised trial comparing intermittent twice weekly treatment and daily treatment

213 children median age 25.9 months

unknown intermittent twice weekly INH 15mg/kg+RMP 15mg/kg+PZA 55mg/kg daily group INH 10mg/kg_RMP 10mg/kg+PZA 25mg/kg

no differences between groups for treatment outcome score one child in twice weekly group considered a relapse no significant side effects documented

26

27

y

Design/location

Patient

population


(0 to 6 months)a

Drug(s)

Outcomes

Stud

South Africa Vallejo 1994 retrospective review

medical records USA

47 children

28

y

Design/location

Patient

population


(0 to 6 months)a

Drug(s)

Outcomes assessing impact of INH prophylaxis on mortality and incidence of TB South Africa

three times weekly HR=0.43 (95% CI: 0.17, 1.09) for all patients there was a statistically significant advantage for INH group compared to placebo for incidence of TB (HR=0.28; 95% CI: 0.10, 0.78) and mortality (HR=0.46; 95% CI: 0.22, 0.95) Grade 3 or 4 toxicity in overall population 4% in INH group vs 6.1% in placebo group

Stud

a this refers to the target population in the Di Mario et al (2009) review; there were no articles available addressing TB treatment in patients aged 0 to 3 months.

TB=tuberculosis; MDR-TB=multidrug-resistant tuberculosis; ING=isoniazid; RMP=rifampicin; PAS=para-aminosalicylic acid; PZA=pyrazinamide; EMB=ethambutol; SM=streptomycin

References Abernathy RS, Dutt AK, Stead WW, et al: Short-course chemotherapy for tuberculosis in children. Pediatrics 1983;72:801-6. Biddulph J. Short course chemotherapy for childhood tuberculosis. Pediatr Infect Dis J 1990;9:794-801. Donald PR, Schoeman JF, Van Zyl LE, et al. Intensive short course chemotherapy in the management of tuberculous meningitis. Int J Tuberc Lung Dis

1998;2:70411. Dubus JC, Piarroux R, Panuel M, Garnier JM, Faure F, Devred P, Unal D.

[Pulmonary tuberculosis in infants. Apropos of 6 cases][Article in French] Arch Pediatr 1994;1:782-6.

Gendrel D, Nardou M, Mouba JF, Gahouma D, Moussavou A, Boguikouma JB.

[Hepatotoxicity of the combination of isoniazid-rifampicin in African children. Role of malnutrition and HB virus] [Article in French] Arch Fr Pediatr 1989;46:645-8.

Gmen A, Ozelic U, Kiper N, Toppare M, Kaya S, Cengizlier R, Cetinkaya F.

Short course intermittent chemotherapy in childhood tuberculosis. Infection 1993;21:324-7.

Hsu KHK. Thirty years after isoniazid: its impact on tuberculosis in children and adolescents. JAMA 1984;251:12831285.

Jacobs RF, Sunakorn P, Chotpitayasunonah T, et al. Intensive short course chemotherapy for tuberculous meningitis. Pediatr Infect Dis J 1992;11:1948. Kiper N, Gmen A, Dilber E, Ozelik U. Effectiveness of short-course, intermittent chemotherapy for tuberculosis in young infants aged less than 6 months. Clin Pediatr (Phila) 1998;37:433-6. Kobayashi K, Haruta T, Maeda H, Kubota M, Nishio T. Cerebral hemorrhage associated with

vitamin K deficiency in congenital tuberculosis treated with isoniazid and rifampin. Pediatr Infect Dis J 2002;21:1088-90.

Mount F, Ferrebee S. Preventive effects of isoniazid in the treatment of primary tuberculosis in

children. N Engl J Med 1961;265:713721. O'Brien RJ, Long MW, Cross FS, Lyle MA, Snider DE Jr. Hepatotoxicity from isoniazid and rifampin among children treated for tuberculosis. Pediatrics

1983;72:491-9.

29

Ormerod L. Rifampicin and isoniazid prophylaxis for tuberculosis. Arch Dis Child 1998; 78: 169-71. Reis FJ, Bedran MB, Moura JA, et al. Six-month isoniazid-rifampin treatment for pulmonary

tuberculosis in children. Am Rev Respir Dis 1990;142:996-9. Sanchez-Albisua I, Vidal ML, Joya-Verde G, et al. Tolerance of pyrazinamide in short course

chemotherapy for pulmonary tuberculosis in children. Pediatr Infect Dis J 1997;16:760-3. Schaaf HS, Gie RP, Kennedy M, Beyers N, Hesseling PB, Donald PR. Evaluation of young

children in contact with adult multidrug-resistant pulmonary tuberculosis: a 30-month follow-up. Pediatrics 2002;109:76571.

Sneag DB, Schaaf HS, Cotton MF, Zar HJ. Failure of chemoprophylaxis with standard antituberculosis agents in child contacts of multidrug-resistant tuberculosis cases. Pediatr Infect Dis J 2007;26:1142-6. Stewart CJ. Tuberculosis infection in a paediatric department. BMJ 1976;1:30-2. Te Water Naude JM, Donald PR, Hussey GD, Kibel MA et al. Twice weekly vs. daily chemotherapy for childhood tuberculosis. Pediatr Infect Dis 2000;19:40510. Vallejo JG, Ong LT, Starke JR. Clinical features, diagnosis, and treatment of tuberculosis in infants. Pediatrics 1994;94:1-7. Visudhiphan P, Chiemchanya S. Evaluation of rifampicin in the treatment of

tuberculous meningitis in children. J Pediatr 1975;87:9836.

Zar HJ, Cotton MF, Strauss S, Karpakis J, Hussey G, Schaaf HS, Rabie H, Lombard CJ. Effect of isoniazid prophylaxis on mortality and incidence of tuberculosis in children with HIV: randomised controlled trial. BMJ

2007;334:136.

30

STREPTOMYCIN IN THE TREATMENT OF UNCOMPLICATED

PULMONARY TB IN CHILDREN When to use

Recommendations Streptomycin should not be used as part of first line treatment regimens for children with pulmonary tuberculosis or tuberculous peripheral lymphadenitis (Strong recommendation, moderate quality evidence)

Domains and considerations Quality of evidence A literature search was conducted to identify publications addressing the use of streptomycin in the treatment of uncomplicated pulmonary TB in children. Medline and EMBASE were searched using the search terms tuberculosis pulmonary, streptomycin, children or pediatric or paediatric. No studies were identified that specifically addressed the use of streptomycin for the treatment of uncomplicated pulmonary TB in children. Articles were found that discussed streptomycin for the treatment of pulmonary TB in children, as well as articles addressing use of streptomycin to treat tuberculosis (either undefined type or primary) in children, and the treatment of pulmonary TB in adults including streptomycin. There were also studies that compared different courses of therapy for the treatment of TB in children, including streptomycin, with the majority of patients having pulmonary TB. The studies are summarized in Table 1. The articles dating from the 1950s describing the use of streptomycin in childhood TB could not be sourced, therefore the quality of these trials could not be determined. However, given the date of the trials they are not likely to be randomized, blinded comparative trials. There was also a 1972 study comparing streptomycin plus isoniazid to isoniazid and thiacetazone in children with primary pulmonary tuberculosis (Gupta and Law, 1972), however this article could also not be sourced. There are two articles addressing the treatment of children with TB which included the use of streptomycin.

Kansoy et al (1996) compared intermittent short course chemotherapy of SM, RMP and INH for two weeks followed by INH and RMP twice weekly for 8.5 months for pulmonary TB with conventional chemotherapy consisting of SM for 40 days, RMP for 9 months and INH for 12 months. At six months of therapy response to treatment was complete in both groups. The Kansoy trial is included in a systematic review (Menon et al. 2010) which compared the effectiveness of intermittent with daily chemotherapy in childhood tuberculosis. The review located four trials with a total of 466 patients, of which 439 had pulmonary TB. Only the Kansoy trial used streptomycin. This review concluded that twice weekly intermittent short course chemotherapy is less likely to cure TB in children compared to daily therapy. The review did not specifically address the role or impact of streptomycin.

For the available trials, none directly addressed the use of streptomycin for uncomplicated pulmonary TB in children, instead they focussed on type of regimen used (e.g. intermittent versus daily treatment). A recent review (Marais et al., 2006) discussed childhood pulmonary TB in regard to diagnosis, treatment, HIV infection and drug resistance. The review recommended streptomycin as a second line drug at a dose of 20-40mg/kg (for disseminated miliary disease), but provided no further dosing or treatment regimen details, nor was the source of the recommended dose provided. The Marais review did note that streptomycin is limited by poor cerebrospinal fluid penetration and intramuscular administration. Uncertainty: YES, given lack of evidence Risks/benefits Benefits limited evidence of benefits

31

STREPTOMYCIN IN THE TREATMENT OF UNCOMPLICATED PULMONARY TB IN CHILDREN

Risks potential for inappropriate dosing as well as adverse events, especially ototoxicity Uncertainty: YES, given lack of evidence Values and acceptability Against: problems with injection based treatment regimens ototoxicity associated with use of streptomycin availability of safe and effective oral alternatives which can be used as first line medicines Uncertainty: YES, given lack of evidence Cost There are no data available assessing the costeffectiveness of streptomycin for the treatment of uncomplicated pulmonary TB in children Uncertainty: YES, given lack of evidence Feasibility streptomycin is already used in the treatment of tuberculosis; however additional paediatric-specific research would clarify use Uncertainty: YES, given lack of evidence Gaps, research needs, comments There is a considerable lack of evidence addressing the use of streptomycin in children with uncomplicated pulmonary TB. However, randomized controlled trials assessing its efficacy and safety in comparison with other drugs may not be warranted given the availability of safe, effective and oral alternatives which can be used as first line medicines Final comment Streptomycin should not be used as part of first line treatment regimens for children with pulmonary tuberculosis. The panel noted the low to moderate quality evidence of efficacy of streptomycin and took into account the risk of toxicity associated with the use of streptomycin, the problems with injection based treatment regimens and the availability of safer, more effective and oral alternatives TB=tuberculosis; INH=isoniazid; RMP=rifampicin; SM=streptomycin

32

Table 1: Summary of articles addressing streptomycin and childhood TB and articles addressing pulmonary TB and children

Trial Title Design Details Streptomycin and children Censi 1951 Streptomycin therapy of pulmonary

tuberculosis in children (Italian) NA NA

Fruhaufowa 1952 Results of streptomycin and paraaminosalicylic acid therapy of tuberculosis in children (Polish)

NA NA

Gupta 1972 A controlled study on progressive primary pulmonary tuberculosis in children treated for one year with dual drugs: streptomycin and isoniazid versus isoniazid and thiacetazone

NA NA

Halikowski 1953 Significance of streptomycin in the treatment of tuberculosis in children; streptomycin in pulmonary tuberculosis in infants (Polish)

NA NA

Krukowska 1952 Streptomycin in the treatment of tuberculosis in children; streptomycin therapy of primary and postprimary pulmonary tuberculosis not including miliary tuberculosis (Polish)

NA NA

Lowys 1951 Streptomycin therapy of pulmonary tuberculosis in children (except miliary forms) (French)

NA NA

McEnery 1953 A five year study of tuberculous children treated with streptomycin

NA NA

Padula 1952 Results of streptomycin and PAS therapy of pulmonary tuberculosis in children (Italian)

NA NA

Ticinese 1953 Streptomycin therapy of tuberculosis in children (Argentinian)

NA NA

Wilkowa 1951 Ocular changes in children with pulmonary tuberculosis treated with streptomycin (Polish)

NA NA

Pulmonary TB and children Brinza 2007 Difficulties in the treatment of pulmonary

tuberculosis in children (Romanian) retrospective review of 254 children with pulmonary TB assessing treatment course, side effects and assessment of cases at end of treatment

abstract does not mention streptomycin, although the majority of patients received 4 or 3-drug regimens, so streptomycin may have been used

Gubkina 2009 Estimation of the possibilities of using unified chemotherapy regimens in new cases of pulmonary tuberculosis in old-age children and adolescents (Russian)

review of children aged 13 to 17 with pulmonary TB

streptomycin was included in treatment regimens along with INH, RMP, PZA and EMB, however no result specific to streptomycin were provided.

33

Trial Title Design Details Kansoy 1996 Superiority of intermittent short course

chemotherapy in childhood pulmonary tuberculosis

open-label comparison of intermittent short-course therapy consisting of SM, RMP and INH daily for 2 weeks followed by INH and RMP twice weekly for 8.5 months with conventional therapy of SM for 40 days, RMP for 9 months and INH for 12 months.

at 6 months of therapy response to treatment was complete in both groups. Authors conclude that a short course, intermittent therapy against pulmonary tuberculosis provides a safe alternative to the conventional, one-year duration chemotherapy

Marais 2006 Childhood pulmonary tuberculosis. Old wisdom and new challenges

review of the diagnosis, treatment, HIV infection and drug resistance in childhood pulmonary TB

streptomycin recommended as second line treatment at dose of 20-40mg/kg for disseminated miliary disease. No further details provided. review notes that streptomycin is limited by poor CSF penetration a intramuscular administration

Menon 2010 Intermittent or daily short course chemotherapy for tuberculosis in children: Meta-analysis of randomised controlled trials

systematic review and meta-analysis of trials comparing intermittent and short course chemotherapy for TB in children

review included 4 trials, of these only one (Kansoy et al., 1996)used streptomycin 439 of 466 patients in the trials had pulmonary TB authors conclude that twice weekly intermittent short course therapy is less likely to cure TB in children as compared to daily therapy.

Shurygin 2009 The efficiency of ultraviolet autologous blood irradiation (UVABI) used in the complex therapy of infiltrative pulmonary tuberculosis in children and adolescents (Russian)

randomized controlled trial comparing patients who received UVABI and those who did not

no mention of streptomycin

Sharma 2008 The DOTS strategy for treatment of paediatric pulmonary tuberculosis in South Delhi, India

retrospective review of 1098 children with pulmonary TB.

average age 11.2 years authors conclude DOTS appears to be highly efficacious

NA=not available; SM=streptomycin; INH=isoniazid; RMP=rifampicin; EMB=ethambutol

34

References Brinza N, Mihaescu T. Difficulties in the treatment of pulmonary tuberculosis in children. Revista

Medico-Chirurgicala a Societatii de Medici Si Naruralisti Din Iasi 2007; 111(4): 852-55. Censi G, Sansotta V. Streptomycin therapy of pulmonary tuberculosis in children (Italian).

Minerva Med 1951; 42(64): 433-35. Fruhaufowa J. Results of streptomycin and paraaminosalicylic acid therapy of tuberculosis in

children (Polish). Pediatr Pol 1952; 27(6): 681-94. Gubkina MF, Ershova NG. Estimation of the possibilities of using unified chemotherapy regimens

in new cases of pulmonary tuberculosis in old-age children and adolescents (Russian). Problemy Tuberkuleza I Boleznej Legkih 2009; 1: 33-36.

Gupta SK, Law SC. A controlled study on progressive primary pulmonary tuberculosis in children

treated for one year with dual drugs: streptomycin and isoniazid versus isoniazid and thiacetazone. J Indian Med Assoc 1972; 59(11): 463-67.

Halikowski B. Significance of streptomycin in the treatment of tuberculosis in children;

streptomycin in pulmonary tuberculosis in infants (Polish). Gruzlica 1953; 21(3): 233-42. Kansoy S, Kurta N, Akit S, Aksoylar S, Yaprak I, alayan S. Superiority of intermittent-short

course chemotherapy in childhood pulmonary tuberculosis. Turkish J Med Sci 1996; 26: 41-43.

Krukowska H, Harasiwicz S. Streptomycin in the treatment of tuberculosis in children;

streptomycin therapy of primary and postprimary pulmonary tuberculosis not including miliary tuberculosis (Polish). Gruzlica 1952; 20(6): 801-15.

Lowys P, Larmoyer M. Streptomycin therapy of pulmonary tuberculosis in children (except

miliary forms) (French). Arch Fr Pediatr 1951; 8(7): 726-46. Marais BJ, Gie RP, Schaaf S et al. Childhood pulmonary tuberculosis. Old wisdom and new

challenges. Am J Respir Crit Care Med 2006; 173: 10781090. McEnery ET. A five year study of tuberculous children treated with streptomycin. JAMA 1953;

153(7): 627-29. Menon PR, Lodha R, Sivanandan S, Kabra SK. Intermittent or daily short course chemotherapy for

tuberculosis in children: Meta-analysis of randomised controlled trials. Indian Pediatrics 2010; 47(1): 67-73.

Padula AA, De Lauro Junior C, De Miranda GP. Results of streptomycin and PAS therapy of

pulmonary tuberculosis in children (Italian). Imprensa Medica 1952; 28(458): 49-55.

35

Sharma S, Sarin R, Khalid UK et al. The DOTS strategy for treatment of paediatric pulmonary

tuberculosis in South Delhi, India. Int J Tuberculosis and Lung Dis 2008; 12(1): 74-80. Shurygin AA. Estimation of the possibilities of using unified chemotherapy regimens in new cases

of pulmonary tuberculosis in old-age children and adolescents (Russian). Problemy Tuberkuleza I Boleznej Legkih 2009; 9:20-23.

Ticinese JB, Ezzaoui JL, Falco JR et al. Streptomycin therapy of tuberculosis in children

(Argentinian). Arch Argent Tisiol 1953; 29(1-2): 31-53. Wilkowa M. Ocular changes in children with pulmonary tuberculosis treated with streptomycin

(Polish). Gruzlica 1951; 19(5): 632-39.

36

EVIDENCE BASE FOR TREATMENT REGIMENS FOR TB MENINGITIS IN CHILDREN What treatment regimen

Recommendations Children with suspected or confirmed tuberculosis meningitis should be treated for with a four drug regimen (HRZE) for 2 months, followed by a two drug regimen for 10 months; the total duration of treatment being 12 months. The dose recommended for the treatment of tuberculosis meningitis are the same as those described for pulmonary TB

H 10 mg/kg (range 10-15 mg/kg); maximum dose: 300mg/day R 15 mg/kg (range 10-20 mg/kg); maximum dose: 600 mg/day Z 35 mg/kg (30-40 mg/kg) E 20 mg/kg (15-25 mg/kg)

(Strong recommendation, low quality evidence) Domains and considerations

Quality of evidence A literature review by Donald (2009)3 assessed the chemotherapy of TB meningitis (TBM) in children in order to make recommendations for the optimal chemotherapeutic management of TBM. Forty-six potentially relevant studies addressing efficacy of different drug regimens and dosages for the management of TBM were identified. Of these, 25 reported paediatric data and 21 reported data for both adults and children. The majority were non-randomized, non-comparative studies. The quality of the studies ranged from low to very low, with the study designs open to a number of sources of bias given lack of randomization, lack of blinding, as well as lack of comparators. No clear conclusions could be drawn from the efficacy studies, given they differed widely in terms of design, drugs used and patient populations. Out of the 46 efficacy studies, 11 studies were identified that reported treatment regimens including rifampicin for the treatment of TB meningitis in children (Table 1). In order to determine optimal treatment duration, the 11 studies were assessed to determine whether 9 month regimens were more effective than 6 or 12 month regimens. In the 11 studies, duration of treatment ranged from 6 months to 2 years. There were no studies that reported clinical outcomes for a duration of treatment of 9 months and only one study used a treatment duration of 6 months. The majority used treatment regimens of at least 12 months. None of the studies from the Donald (2009) review were entered into GRADE, given the lack of comparative data. The panel noted that although there are many observational studies of treatment of children with TBM, they are of very low quality. The panel also noted the existence of a number of treatment guidelines (American Thoracic Society and British Thoracic Society) that recommend longer durations of treatment, up to 2 years in some cases. Uncertainty: YES, given low quality of the evidence and relative lack of paediatric evidence. Risks/benefits Benefits effective treatment, with the risk of adverse events and development of drug resistance minimized.

3 Donald PR. 2009. The chemotherapy of tuberculous meningitis in children. A literature review. (submitted for publication). Commissioned by WHO Department of Medicines, Access and Rational Use, Essential Medicines and Pharmaceutical Policies, WHO HQ Geneva.

37

EVIDENCE BASE FOR TREATMENT REGIMENS FOR TB MENINGITIS IN CHILDREN Risks inappropriate treatment regimens and dosing Risks outweigh benefits given lack of evidence in paediatric population Values and acceptability In favour: based on the severity of morbidity and mortality with this disease prompt treatment for a long duration is warranted Uncertainty: YES Cost there are no studies of cost or cost-effectiveness in TBM in children. Given the relative lack of efficacy and safety data, this is expected. Caution should be used when considering costs and cost-effectiveness for other types of TB and other populations, as results may not be generalizable. Uncertainty: YES, given the lack of paediatric specific data and cost analyses. Feasibility current evidence does not strongly support current treatment regimens Uncertainty: YES Gaps, research needs, comments the available evidence assessing the efficacy and safety of TBM treatment regimens is limited and of poor design. a randomised trial of different lengths of treatment of tuberculous meningitis Final comment doses should be at least those recommended above and use of the maximum recommended range should be considered given the uncertain penetration of the medicines into the CNS TBM=tuberculosis meningitis; INH=isoniazid; RMP=rifampicin; PZA=pyrazinamide; EMB=ethambutol; MDR-TB=multidrug resistant tuberculosis; CNS=central nervous system

38

Table 1: Summary of studies that included rifampicin in the treatment regimen for treatment of TB meningitis in children Trial Design Treatment N Outcomes Donald 1998 open-label non-

randomized study of intensive short course treatment

6 months INH/RMP/PZA/ETH doses INH 20mg/kg; RMP 20mg/kg; PZA 40mg/kg; ETH 20mg/kg

Stage 1 - 4 Stage II 52 Stage III 39

10 Stage III patients (25.6%) died before completion of therapy and 2 Stage III patients (5.1%) died after discharge 3 Stage II patients (5.8%) died before completion of therapy 12 of 29 (41.4%) Stage III survivors had major motor defects 10 of 49 (20.4%) Stage II survivors had major motor defects

Faella 2006 retrospective review

2 months INH/RMP/SM + 10-18 months INH/RMP doses INH 5mg/kg; RMP 10mg/kg; SM 20mg/kg EMB/PZA given to 10 patients, doses not provided


4 deaths (12.5%), all in Stage II patients 6 patients (18.8%) had one or more serious sequelae 3 (9.4%) patients had cytolytic hepatitis with ALT levels 3 times greater than normal, and had INH dose reduced

Farinha 2000 retrospective review

2 year course of INH/RMP plus initial 3 months of SM + 20 doses intrathecal or intraventricular SM. Doses not provided 2 months INH/RMP/PZA/SM or EMB + 10 months INH/RMP. Doses not provided

Stage 1 - 2 Stage II 10 Stage III 21 tuberculoma - 5

5 patients (13% of overall sample) died; all were stage III (23.8%) 19 (50%) either died or developed permanent sequelae 11 of 14 in Stage III (78%) and 3 of 10 (30%) in Stage II developed neurological sequelae

Humphries 1990

retrospective review

all patients received INH (mean duration 23.8 months) 84% SM (5.5 months) 85% ETH (19 months) 84% RMP (11.6 months) 47% EMB (14.4 months) 44% PZA (11.9 months) doses not provided


in Stage II, 1 patient died (1.3%), 7 (9.0%) had mild, 6 (7.7%) had moderate and 3 (3.8%) had severe neurological sequelae in Stage III, 12 patients died (16.7%), 4 (5.6%) had mild, 18 (25.0%) had moderate and 23 (31.9%) had severe neurological sequelae

Jacobs 1992 open-label, non-randomized study of intensive short course treatment

2 INH/SM/EMB + 10 INH/EMB or 2 RMP/SM/EMB + 10 RMP/EMB (regimen A) 2 INH.RMP/SM + 7 INH/RMP (regimen B) 2 INH/RMP/PZA/SM + 4 INH/RMP (regimen C) doses: INH 15mg/kg; SM 40mg/kg; RMP 20mg/kg; EMB 25mg/kg; PZA 30mg/kg


there were 11 deaths overall (20.8%) in Stage III there were 8 deaths (50%), 3 in patients using regimens A or B and 5 in patients using regimen C in survivors, 19 patients had sequelae 2 patients in Stage III had sequelae (25% of survivors) results for regimens A and B combined

39

Trial

40

Design Treatment N Outcomes Rahajoe 1979 randomized,

open-label study of treatment with INH, RMP and SM

INH/SM/RMP INH/PAS/SM Doses INH 20mg/kg; SM 30-50mg/kg; RMP 10-15mg/kg; PAS 200-300mg/kg INH for 18 months, SM for 1 month in group 1 or 3 months in group 2, RMP for 6 months and PAS for 12 months


6 patients treated with INH/SM/RMP died, all Stage III 7 patients treated with INH/SM/RMP had neurological sequelae, all Stage III cases 5 patients treated with INH/PAS/SM died, with 4 of 5 being Stage III cases 11 patients treated with INH/PAS/SM had neurological sequelae, 9 were Stage III cases and 2 were Stage II

Ramachandran 1989

retrospective review of long-term follow-up of 3 open-label, non-randomised studies

3 regimens used, all had INH/SM/RMP with or without PZA for 2 months + INH/EMB for 10 months doses not reported

119 (Stage not provided)

17 (14.3%) died at end of 1 year treatment of remaining 102, 3 (2.9%) had severe sequelae, 32 (31.4%) had moderate sequelae and 15 (14.7%) had mild sequelae

Schoeman 2004

randomized, double-blind trial comparing thalidomide and placebo in addition to INH/RMP/PZA/ETH

INH/RMP/PZA/ETH + patients randomized to thalidomide or placebo doses INH 20mg/kg; RMP 20mg/kg; PZA 40mg/kg; ETH 20mg/kg treatment duration not stated, although some 6 month results are provided


trial stopped early due to adverse events and deaths associated with thalidomide 4 deaths, all Stage III patients (30.8%) receiving thalidomide

Visudhiphan 1989

open-label, non-randomized study of treatment using INH and RMP

12 months INH/RMP doses INH 10-15mg/kg; RMP 15mg/kg

Stage 1 - 5 Stage II 25 Stage III 21 4 lost to follow-up so 47 analysed

3 deaths (6.4% of overall sample), all patients were in Stage III (14.3%) neurologic deficits in 13 (27.7% overall), 5 in Stage II (20.0%) and 8 in Stage 3 (38.1%)

Waeker 1990 retrospective review of medical records

INH used in all patients, RMP in 26 (86.7%), EMB in 16 (53.3%), SM in 11 (36.7%), PZA in 2 (6.7%) treatment duration and doses not provided


1 death in a Stage III patient (5.9%) in Stage III 15 had major sequelae (88.2%) in Stage II 5 had major sequelae (50%) and 2 had minor sequelae (20%)

Yaramis 1998 retrospective review

INH/RMP for 12 months, with SM or PZA also used in first 2 months Doses INH 10-15mg/kg; RMP 15-20mg/kg; SM 20-25mg/kg; PZA 25-35mg/kg


49 deaths overall (22.9%) 14 deaths (11.7%) in Stage II patients and 31 (25.8%) with developmental sequelae 35 deaths (48.6%) in Stage III patients and 27 (37.5%) with developmental sequelae

References Donald PR, Schoeman JF, van Zyl LE, De Villiers JN, Pretorius M, Springer P. Intensive short course chemotherapy in the management of tuberculous meningitis. Int J Tuberc Lung Dis 1998; 2: 704-711. Faella FS, Pagliano P, Attanasio V, et al. Factors influencing the presentation and outcome of tuberculous meningitis in childhood. In Vivo 2006; 20: 187-192. Farinha NJ, Razali KA, Holzel G, Morgan G, Novelli VM. Tuberculosis of the central nervous system in children: a 20-year survey. J Infect 2000 41: 61-68. Humphries MJ, Teoh R, au J, Gabriel M. Factors of prognostic significance in Chinese children with tuberculous meningitis. Tubercle 1990; 71: 161-168. Jacobs RF, Sunakorn P, Chotpitayasunonah T, et al. Intensive short course chemotherapy for tuberculous meningitis. Pediatr Infect Dis J 1992;11:1948. Rahajoe NN, Rahajoe N, Boediman I, et al. The treatment of tuberculous meningitis in children with a combination of isoniazid, rifampicin and streptomycin preliminary report. Tubercle 1979;60:24550. Ramachandran P, Duripandian M, Reetha AM, Mahalakshmi SM, Prabhakar R. Long-term status of children treated for tuberculous meningitis in South India. Tubercle 1989; 70: 235-239. Schoeman JF, Springer P, Janse van Rensburg et al. Adjunctive thalidomide therapy for childhood tuberculous meningitis: results of ramdomized study. J Child Neurol 2004; 19: 250-257. Visudhiphan P, Chiemchanya S. Tuberculous meningitis in children: treatment with isoniazid and rifampicin for twelve months. J Pediatr 1989; 114: 875-879. Waecker NJ, Connor JD. Central nervous system tuberculosis in children: a review of 30 cases. Pediatr Infect Dis J 1990; 9: 539-543. Yarami A, Gurkan F, Elevli M, et al. Central nervous system tuberculosis in children: a review of 214 cases. Pediatrics 1998; 102 (5) URL: http//wwwpediatrics.org/cgi/content/full/102/5/e49.

41

EVIDENCE BASE FOR TREATMENT REGIMENS

FOR OSTEO-ARTICULAR TB IN CHILDREN Treatment regimen

Recommendations Children with suspected or confirmed osteo-articular tuberculosis should be treated with a four drug regimen (HRZE) for 2 months followed by a two drug regimen (HR) for 10 months; the total duration of treatment being 12 months. The doses recommend for the treatment of osteo-articular tuberculosis are the same as those described for pulmonary TB.

H 10 mg/kg (range 10-15 mg/kg); maximum dose 300 mg/day R 15 mg/kg (range 10-20 mg/kg); maximum dose 600 mg/day P 35 mg/kg (30-40 mg/kg) E 20 mg/kg (15-25 mg/kg)

(Strong recommendation, low quality evidence) Domains and considerations

Quality of evidence A review by Donald (2010)4 assessed the literature relating to osteo-articular TB with the aim of making recommendations for chemotherapy of the disease in children. Fifty-one potentially relevant citations were retrieved of which only 11 contained paediatric specific data. Sample sizes ranged from 4 to150. Seven of the studies had less than 25 participants. None of the studies were randomized, double-blind comparative studies. The studies focused on the outcome of no relapse, although the duration of follow up was often not reported. The quality of the studies ranged from low to very low, with the study designs open to a number of sources of bias given lack of randomization, lack of blinding as well as lack of comparators. Treatment regimens generally lasted for 12 months and most of the regimens included INH and RMP. None of the studies included in the Donald (2010) review were entered into GRADE, given the lack of comparative data. A summary of the trials including paediatric patients only is provided in Table 1 below. The trials including both adults and children are not provided as the majority do not provide results separately for adults and children, and it may not be appropriate to assume results can be applied to children. Uncertainty: YES, given low quality of the evidence, relative lack of paediatric evidence and lack of appropriate analyses of available data. Risks/benefits Benefits effective treatment, with the risk of adverse events and development of drug resistance minimized Risks inappropriate treatment regimens and dosing Risks outweigh benefits given lack of evidence in paediatric population

4 Donald PR. 2009. The chemotherapy of osteo-articular tuberculosis in children. A literature review. (unpublished). Commissioned by WHO Department of Medicines, Access and Rational Use, Essential Medicines and Pharmaceutical Policies, WHO HQ Geneva.

42

43

EVIDENCE BASE FOR TREATMENT REGIMENS FOR OSTEO-ARTICULAR TB IN CHILDREN

Values and acceptability In favour: pharmacological arguments support the longer duration of treatment for infections of bones and joints no evidence of increased risk of toxicity associated with increased duration of treatment Against: evidence is low quality Uncertainty: YES, given lack of evidence Cost There are no studies of cost or cost-effectiveness in osteo-articular TB in children. Given the relative lack of efficacy and safety data, this is expected. Caution should be used when considering costs and cost-effectiveness for other types of TB and other populations, as results may not be generalizable. Uncertainty: YES, given the lack of paediatric specific data and cost analyses. Feasibility current evidence does not strongly support recommended treatment regimens Uncertainty: YES, given lack of evidence Gaps, research needs, comments There are no randomised controlled trials assessing different treatment regimens for osteo-articular TB in children. The available evidence includes differing populations and treatments and is open to a number of sources of bias. Consequently, the use of RCTs to address research questions would allow more definitive conclusions to be drawn and would allow for improved consideration of the relationship between treatment and outcome. Final comment The panel noted that although the evidence is of low quality, the treatment regimens used in children were generally given for at least 12 months duration and the studies reported ' no relapse' as the main outcome, although the duration of follow-up was often poorly reported. The panel took into account the pharmacological arguments to support the longer duration of treatment for infections of bones and joints and the lack of evidence to indicate an increased risk of toxicity associated with increased duration of treatment, and the difficulty of determining cure in patients treated for osteo-articular TB.

44

Table 1: Summary of paediatric studies of osteo-articular TB treatment Study

Design

Patients

Drug(s)

Treatment duration

Outcomes

Agrawal 2008

review surgical treatment of tuberculotic osteomyelitis

7 children aged 4 to 18 years with TB of the rib

INH 5mg/kg RMP 10-15mg/kg PZA 25mg/kg EMB 15mg/kg

12 months surgical excision in all cases no relapse in 5-8 years follow-up

Altman 1996 review of use of chemotherapy and anterior/posterior spinal fusion

6 children with severe spinal TB

INH, RMP and PAS, doses not provided

12 months follow-up of 9.5 to 13.7 years with no relapse

Bailey 1972 retrospective review 100 children 18 months to 10 years of age Potts disease

INH 5-10mg/kg SM 20mg/kg (6 months) PAS 200mg/kg

At least 18 months

94% had complete working capacity and 6% had partial working capacity no mention of relapse

Govender 2007

retrospective review of clinical and radiographic outcome of children treated operatively and non-operatively

58 children with cervical spine TB, with age ranging from 1.9 to 14 years

INH 5-10mg/kg RMP 10-20mg/kg PZA 25mg/kg EMB 15mg/kg

12 months no relapses recorded

Hakimi 2008 review of 4 cases of tuberculotic osteomylelitis

4 children aged 10 to 16 months with TB disease of knee, ankle, wrist

INH, RMP, EMB and PZA followed by INH and RMP

INH, RMP, EMB and PZA for nine months followed by INH and RMP for 7 months

satisfactory radiological recovery within 6 months

Kalra 2007 review of patients with tubercular atlantoaxial dislocation, treated with surgery and chemotherapy

17 children with atlanto-axial TB, aged from 5 to 16 years

INH 10-20mg/kg RMP 10-20mg/kg PZA 20-35mg/kg EMB 15mg/kg

PZA for 3 months, EMB for 12 months, RMP and INH for 18 months

no relapses recorded

MRC 1973 unknown design comparison of bed

150 children with spinal TB

INH 10mg/kg SM 30mg/kg

18 months spinal TB could be managed without

45

y

Design

Patients

Drug(s) Treatment duration

Outcomes

Stud

rest with ambulant outpatient treatment in patients receiving chemotherapy

PAS 200mg/kg admission to hospital for bed rest

Papavasiliou + Petropoulos 1981

report on cases of bone and joint TB surgical curettage plus chemotherapy followed by immobilization in plaster

10 children with bone and joint TB aged 18-30 months

INH 5mg/kg RMP 30mg/kg SM 15mg/kg

6 months (SM for 6 weeks)

no relapse recorded during at least 2 years follow-up

Rasool 1994 report of cases of cystic tuberculosis of bone

13 children mean age 5 years

doses not provided INH 12 months; RMP 6 months; PZA 12 months

healing in all cases no relapses reported

Shih 1997 report of 24 cases of long bone TB biopsy, curettage and chemotherapy provided

24 children with long bone TB

INH10-20mg/kg RMP 10-20mg/kg

6 months follow-up to 32 months, no relapses

Singh 1992 review of cases 104 children with osteo-articular TB

INH 5mg/kg RMP 10mg/kg EMB 15mg/kg

INH 18 months; RMP 6 months; EMB 12 months

clinical/radiological disease healing from 12-14 months n 74% of patients no recurrence

TB=tuberculosis; INH=isoniazid; RMP=rifampicin; PAS=para-aminosalicylic acid; PZA=pyrazinamide; EMB=ethambutol; SM=streptomycin

References Agrawal V, Joshi MK, Jain BK, Mohanty D, Gupta A. Tuberculotic osteomyelitis of rib -

a surgical entity. Interact Cardiovasc Thoracic Surg 2008; 7: 1028-1030. Altman GT, Altman DT, Frankovitch KF. Anterior and posterior fusion for children with

tuberculosis of the spine. Clin Orthop Rel Res 1996; 325: 225-231. Bailey HL, Gabriel M, Hodgson AR, Shin JS. Tuberculosis of the spine in children. J

Bone Joint Surg 1972; 54-A: 1633-1657. Govender S, Ramnarain A, Danaviah S. Cervical spine tuberculosis in children. Clin

Orthop Rel Res 2007; 460: 78-85. Hakimi M, Hashemi F, Mirzaie AZ, Pour AH, Kosari H. Tuberculoous osteomyelitis of

the long bones and joints. Ind J Pediatr 2008; 75: 505-508. Kalra SK, Kumar R, Mahapatra AK. Tubercular atlantoaxial dislocation in children: an

institutional experience. J Neurosurg 2007; 107(2 Suppl Pediatrics): 111-118. MRC Working Party on Tuberculosis of the Spine. A controlled trial of ambulant out-

patient treatment and in-patient rest in bed in the management of tuberculosis of the spine in young Korean patients on standard chemotherapy. J Bone Joint Surg 1973 (a); 55-B: 678-697.

Papavasiliou VA, Petropoulos AV. Bone and joint tuberculosis in childhood. Acta Tuberc Scand 1981; 52: 1-4. Rasool MN, Govender S, Naidoo KS. Cystic tuberculosis of bone in children. J Bone

Joint Surg 1994; 76-B: 113-117. Shih H-H, Hsu RW-W, Lin T-Y. Tuberculosis of the long bone in children. Clin Orthop

Rel Res 1997; 335: 246-252. Singh SB, Saraf SK, Singh LI, Srivastava TP. Osteoarticular tuberculosis in children.

Indian Pediatr 1992; 29: 1133-1137.

46

USE OF FLUOROQUINOLONES IN CHILDREN WITH MDR-TB When to use

Recommendations Children with proven or suspected pulmonary tuberculosis or TB meningitis caused by multiple drug resistant bacilli can be treated with a fluoroquinolone in the context of a well functioning MDR-TB programme and within an appropriate MDR-TB regimen. This should be done by a clinician experienced in the management of paediatric tuberculosis (Strong recommendation, very low quality evidence)

Domains and considerations Quality of evidence There are no randomized controlled trials, nor are there any non-randomized studies specifically assessing the efficacy and safety of fluoroquinolones (FQs) for the treatment of multi-drug resistant tuberculosis (MDR-TB) in children. There is one US study (Feja et al., 2008) which assesses management of 20 paediatric patients (mean age 2.7 years) with MDR-TB in New York city. Fourteen (60%) of these patients were treated with FQs (ofloxacin, ciprofloxacin, levofloxacin). The paper does not provide any drug-specific efficacy or safety results, however there was no evidence that recurrent disease occurred amongst the patients. Only 11 patients had available adverse event data, and of these four (36%) experienced adverse events, but there are no details provided as to which drug(s) these patients were taking. There is a 2008 Cochrane review (Ziganshina and Squire) which was up-to-date in 2007 and assessed the use of FQs for tuberculosis. None of the trials included in the review had paediatric patients. There is also a 2007 review of the use of FQ for the treatment of pulmonary TB, however none of the 15 studies which used FQs to treat MDR-TB included paediatric patients. There are four publications addressing the safety of FQ in paediatric patients (Grady 2003; Chalumeau et al., 2003; Yee et al., 2002; Noel et al., 2007), as well as one review of FQs in infants and children (Schaad, 2005), however none of these papers consider the use of FQs in patients with MDR-TB. These are summarised in Table 1 below. A review prepared for the Guideline group (Goldman and Kearns 2010)5 summarised available data on use of FQ in children. The authors report the Mitnick et al (2008) retrospective review which assessed the use of FQs in extensively drug-resistant tuberculous. There were no children included in the Mitnick review, with the average age of the patients greater than 30 years. GRADE tables are provided for the Yee et al (2002) and Chalumeau et al (2003) studies (Table 2). Given the lack of comparative data in the relevant population (children with MDR-TB receiving FQ treatment) no other GRADE tables were produced for the papers described above. Overall, the quality of evidence is very low, given study design, indirectness and inconsistency. Most studies did not report a significant association between FQ use and joint abnormalities, although Chalumeau et al (2003) reported a higher level of adverse events with FQ patients compared to controls receiving other antibiotics. Uncertainty: YES Risks/benefits 5 Goldman JA and Kearns GL. 2009. Fluoroquinolone use in paediatrics: focus on safety and place in therapy (unpublished). Commissioned by WHO Department of Medicines, Access and Rational Use, Essential Medicines and Pharmaceutical Policies, WHO HQ Geneva.

47

USE OF FLUOROQUINOLONES IN CHILDREN WITH MDR-TB Benefits oral bioavailability and tissue penetration broad antimicrobial spectrum predictable concentration-effect relationships low incidence of development of microbial resistance Risks potential for cartilage damage in paediatric patients, based on cartilage damage in juvenile animal models Uncertainty: YES, given lack of conclusive evidence for both efficacy and safety in the paediatric TB population Values and acceptability In favour: potential for effectiveness in multidrug-resistant disease oral administration Against: potential for adverse events lack of long term safety data in children misuse may lead to increased resistance Uncertainty: YES, given lack of evidence

48

USE OF FLUOROQUINOLONES IN CHILDREN WITH MDR-TB Cost There are no data available assessing the costeffectiveness of FQs for the treatment of MDR-TB in paediatric patients. There is a 2002 study (Suarez et al) which assessed the cost-effectiveness of second-line TB drugs in a middle-income country (Peru). A total of 466 patients (5 less than 15 years of age) were included, 298 (87%) of which had MDR-TB. The mean cost per DALY gained was $USD211. Uncertainty: YES, as the available data are not specific to paediatric patients, and also include patients with conditions other than MDR-TB. Feasibility formulations are stable and available fluoroquinolones are registered for use in TB in some countries Uncertainty: YES, given lack of evidence Gaps, research needs, comments There is a considerable lack of evidence addressing the use of FQs in paediatric patients with MDR-TB. As such, there is a need for randomised controlled trials addressing the use of these agents in the relevant population The panel noted the lack of long term safety data for the use of fluoroquinolones in children and the paucity of evidence for their use in the treatment of tuberculosis in children The panel considered indirect evidence from the treatment of cystic fibrosis and osteomyelitis which indicated that longer term use was not associated with an increased risk of joint abnormalities in children. Where arthralgia has been described in studies it has been completely reversible The panel took into account the pharmacological arguments for the use of fluoroquinolones, such as their good penetration of tissue and oral bioavailability and predictable pharmacokinetics in children Research needs include: RCTs comparing regimens including a fluoroquinolone to standard regimens in the context of MDR-TB; collection of long term safety data and validation of biomarkers for cartilage damage and studies to elicit their usefulness in the treatment of skeletal TB Final comment The panel reached a consensus that in the context of multi-drug resistant tuberculosis, the benefits of treatment outweighed the risks. MDR-TB=multidrug resistant tuberculosis; FQ=fluoroquinolone

49

50

Table 1: Summary of papers addressing safety of FQs in paediatric patients Trial Design Outcomes Chalumeau 2003

observational comparative cohort study comparing patients receiving systemic FQs and matched controls receiving other antibiotics

rate of potential adverse events was higher in the FQ group OR=3.7; 95% CI: 1.9, 7.5), with musculoskeletal potential adverse events occurring more frequently in the FQ group (3.8%) compared to controls (0.4%). authors conclude that the higher rates of adverse events in the FQ group supports the American Academy of Pediatrics statement restricting off-label use of FQs in paediatric patients to second-line use in limited situations.

Grady 2005 report of retrospective reviews and RCTs assessing the use of ciprofloxacin in children

rate of arthralgia and quinolone-induced cartilage toxicity were low no differences in efficacy and safety between ciprofloxacin and the comparator drugs, and no evidence of joint toxicity

Noel 2007 safety profile of 2,523 children treated with levofloxacin

reports of musculo-skeletal events were higher in children treated with levofloxacin compared to those treated with non-FQ antibiotics. Five patients with musculoskeletal complaints underwent CT or MRI which failed to reveal any structural abnormalities, and there was no association between levofloxacin exposure and long-term joint abnormalities or growth impairment.

Schaad 2005

literature review for quinolone-induced cartilage toxicity

there was no unequivocal documentation of quinolone-induced arthropathy in patients as described in juvenile animals; clinical observations temporally related to quinolone use are reversible episodes of arthralgia that do not lead to long-term sequelae when treatment is discontinued; most joint complaints associated with quinolone use are coincidental and do not represent adverse effects.

Yee 2002 retrospective observational study comparing children with a history of FQ use to those with exposure to azithromycin

no statistically significant difference in the risk of tendon or joint disorders between the two groups

Author(s): P. Whyte Date: 2010-03-20 Question: Should fluoroquinolones vs. other antibiotics be used in paediatric patients?1 Settings: Bibliography: Yee 2002; Chalumeau 2003 Table 2: Comparisons of FQs and other antibiotics in paediatric patients adverse events

Summary of findings Quality assessment No of patients Effect

No of studies Design Limitations Inconsistency Indirectness Imprecision

Other considerations fluoroquinolones

other antibiotics

Relative(95% CI)

AbsoluteQuality

Importance

levofloxacin vs. azithromycin (tendon or joint disorders) 12 observational

studies serious3 no serious

inconsistencyserious4 no serious

imprecisionnone

13/1593 (0.8%) 118/15073 (0.8%)

RR 1.04 (0.55 to

1.84)

0 more per 1000 (from 4 fewer to 7 more)

VERY LOW IMPORTANT

ciprofloxacin vs. control (tendon or joint disorders) 12 observational

studies serious3 no serious

inconsistencyserious4 no serious

imprecisionnone

37/4531 (0.8%) 118/15073 (0.8%)

RR 1.04 (0.72 to

1.51)

0 more per 1000 (from 2 fewer to 4 more)

VERY LOW IMPORTANT

FQs vs. other antibiotics (potential adverse events) 15 observational

studies serious6 serious7 serious4 serious8 none

47/276 (17%) 13/237 (5.5%)

OR 3.7 (1.9 to

7.5)

122 more per

1000 (from 44 more to

248 more)

VERY LOW IMPORTANT

51

52

1 Given that all studies are non-randomized, non-blinded and do not include patients with MDR-TB, the quality of evidence is very low. 2 Yee 2002 3 Retrospective review of medical records, thus susceptible to bias given lack of randomization and blinding. 4 The study did not include any patients with TB. 5 Chalumeau 2003 6 observational comparative cohort study assessing paediatric patients taking FQs or other antibiotics. There is risk of bias given lack of randomization and blinding. 7 Results of this study, with significantly greater occurrence of adverse events in patients using FQs, is not consistent with most other observational studies, which r

whohtmtb 2010 13 annex

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